1.0 APPLICABILITY
This
policy is mandatory for the reimbursement of services provided either
by network or non-network providers. However, alternative network
reimbursement methodologies are permitted when approved by the Defense
Health Agency (DHA) and specifically included in the network provider agreement.
3.0 POLICY
Appropriate
bill types:
3.1 Bill Types
Subject To Outpatient Prospective Payment System (OPPS)
All outpatient hospital bills (bill
types 013X with Condition Code 41, 013X without Condition Code 41,
014X for diagnostic services), with the exception of bills from
providers excluded under
Section 1, paragraph 3.4.1.2.5 will be subject
to the OPPS.
3.2 Reporting Requirements
3.2.1 Payment of outpatient hospital claims
will be based on the “from” date on the claim.
3.2.2 Hospitals should
make every effort to report all services performed on the same day
on the same claim to ensure proper payment under OPPS.
3.2.3 Each line item
on the Centers for Medicare and Medicaid Services (CMS) 1450 UB-04
Claim Form must be submitted with a specific date of service to
avoid claim denial. The header dates of service on the CMS 1450
UB-04 may span, as long as all lines include specific dates of service
within the span on the header.
3.3 Procedures for Submitting Late Charges
3.3.1 Hospitals may
not submit a late charge bill (frequency 5 in the third position
of the bill type) for bill types 013X.
3.3.2 They must submit an adjustment bill
for any services required to be billed with Healthcare Common Procedure
Coding System (HCPCS) codes, units, and line item dates of service
by reporting frequency 7 or 8 in the third position of the bill
type. Separate bills containing only late charges will not be permitted.
Claims with bill type 0137 and 0138 should report the original claim
number in Form Location (FL) 64 on the Centers for Medicare and
Medicaid Services (CMS) 1450 UB-04 Claim Form.
3.3.3 The submission
of an adjustment bill, instead of a late charge bill, will ensure
proper duplicate detection, bundling, correct application of coverage
policies and proper editing of Outpatient Code Editor (OCE) under
OPPS.
Note: The contractors will take appropriate
action in those situations where either a replacement claim (Type
of Bill (TOB) 0137)) or voided/canceled claim
(TOB 0138) is received without an initial claim (TOB 0131) being
on file. Adjustments resulting in overpayments will be set for recoupment
allowing an auto offset.
3.4 Claim Adjustments
Adjustments
to OPPS claims shall be priced based on the from date on the claim
(using the rules and weights and rates in effect on that date) regardless
of when the claim is submitted. Contractor’s shall maintain at least
three years of APC relative weights, payment rates, wage indexes, etc.,
in their systems. If the claim filing deadline has been waived and
the from date is more than three years before the reprocessing date,
the affected claim or adjustment is to be priced using the earliest APC
weights and rates on the contractor’s system.
3.5 Proper Reporting
of Condition Code G0 (Zero)
Hospitals should
report Condition Code G0 when multiple medical visits
occurred on the same day in the same revenue center but the visits
were distinct and constituted independent visits. Refer to the Medicare
Claims Processing Manual, Chapter 4, Section 180.4 for proper reporting
of Condition Code G0.
3.6
Clinical
Diagnostic Laboratory Services Furnished to Outpatients
3.6.1 Hospitals should
report HCPCS codes for clinical diagnostic laboratory services.
3.6.2 Beginning
January 1, 2014, most laboratory tests will be packaged under OPPS.
Laboratory tests should be reported on TOB 13X. Laboratory tests
may be separately paid when billed on TOB 14X in the following circumstances:
3.6.2.1 Non-patient
laboratory specimen tests.
3.6.2.2 When the hospital
only provides laboratory tests (directly or under arrangement) and patient
receives no other hospital outpatient services during the same encounter.
3.6.2.3 When the laboratory
test is provided (directly or under arrangement) during the same encounter
as other hospital outpatient services that is clinically unrelated
to the other hospital outpatient services, and the laboratory test
is ordered by a different practitioner than the practitioner who
ordered the other hospital outpatient services.
3.6.3 Beginning January 1,
2016, laboratory tests (regardless of date of service) on a claim
with a service that is assigned a Status Indicator (SI) of S, T,
or V, unless an exception applies or the laboratory test
is “unrelated” to the other service(s) on the claim, will be conditionally
packaged and will be assigned SI of Q4. When laboratory
tests are the only service(s) on a claim, a separate payment may
be made.
3.7 OPPS Modifiers
TRICARE requires
the reporting of HCPCS Level I and II modifiers for accuracy in
reimbursement, coding consistency, and editing.